4Results Volunteer Mentor Application
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Name:
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Phone (Home):
Phone (Cell):
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Address:
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E-mail:
Phone (Work):
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City, State, Zip:
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Birthday:
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Days Available:
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Times Available:
Daytime
After School
Evening
Weekend
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Do you have personal transportation?
Yes
No
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Do you have auto insurance?
Yes
No
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Driver's License Number:
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Expiration Date:
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Person to contact in case of emergency:
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Have you ever been convicted of a felony?
Yes
No
If yes, please state offense:
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Are you presently employeed?
Yes
No
Position:
Employer Name and Address:
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How did you hear about 4Results?
4Results Website
Volunteer Match
Poster
Online Search
Friend
Event
Other
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Why do you want to be a mentor?
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Please list three references (not relatives) who have known you for at least a year:
* Name
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Phone:
E-mail:
Address:
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Name:
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Phone:
E-mail:
Address:
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Name:
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Phone:
E-mail:
Address:
Interests
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Check all that apply:
Arts/Crafts
Reading
Basketball
Golf
Soccer
Football
Baseball
Tennis
Swimming
Bowling
Mini Golf
Shopping/going to the mall
Going to the park
Outdoor Activities
Hiking
Riding Bikes
Rollerblading
Animals
Music
Listening to Music
Playing an Instrument
Cultural Events
Theatre
Museums
Concerts
Other:
The following information is for research purposes only. You are not required to answer any of the following questions.
Primary Language:
English
Spanish
Russian
Other
Secondary Language:
English
Spanish
Russian
Other
Primary Religion:
Buddhist
Catholic
Christian
Hindu
Jewish
Muslim
Protestant
Other
None/Atheist
Sexual Orientation:
Bisexual
Gay/Lesbian
Heterosexual
Questioning
Transgender
Marital Status:
Single
Married
Divorced
Domestic Partnership
Separated
Widowed
Household Income:
< $10,000
$10,000 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
> $150,000
Race or Ethnic Identity:
Hispanic or Latino
Caucasian
African American
Native Hawaiian or Pacific Islander
Asian
American Indian or Alaskan Native
Other
Military Service:
Yes
No
Smoker:
Yes
No
Disabled:
Yes
No
Type of disability:
Education Level:
No Degree
H.S. Degree or GED
Some College
Associates Degree
Bachelors Degree
Masters Degree
Terminal Degree (PhD, JD, MD, etc)
Other
Degree Year:
School Name:
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Indicates Response Required
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